Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study

Abstract

BackgroundWe describe trends in characteristics and outcomes among adults initiating HIV care and treatment in Ethiopia from 2006-2011.MethodsWe conducted a retrospective longitudinal analysis of HIV-positive adults (≥15 years) enrolling at 56 Ethiopian health facilities from 2006–2011. We investigated trends over time in the proportion enrolling through provider-initiated counseling and testing (PITC), baseline CD4+ cell counts and WHO stage. Additionally, we assessed outcomes (recorded death, loss to follow-up (LTF), transfer, and total attrition (recorded death plus LTF)) before and after ART initiation. Kaplan-Meier techniques estimated cumulative incidence of these outcomes through 36 months after ART initiation. Factors associated with LTF and death after ART initiation were estimated using Hazard Ratios accounting for within-clinic correlation.Results93,418 adults enrolled into HIV care; 53,300 (57%) initiated ART. The proportion enrolled through PITC increased from 27.6% (2006–2007) to 44.8% (2010–2011) (p < .0001). Concurrently, median enrollment CD4+ cell count increased from 158 to 208 cells/mm3 (p < .0001), and patients initiating ART with advanced WHO stage decreased from 56.6% (stage III) and 15.0% (IV) in 2006–2007 to 47.6% (stage III) and 8.5% (IV) in 2010–2011. Median CD4+ cell count at ART initiation remained stable over time. 24% of patients were LTF before ART initiation. Among those initiating ART, attrition was 30% after 36 months, with most occurring within the first 6 months. Recorded death after ART initiation was 6.4% and 9.2% at 6 and 36 months, respectively, and decreased over time. Younger age, male gender, never being married, no formal education, low CD4+ cell count, and advanced WHO stage were associated with increased LTF. Recorded death was lower among younger adults, females, married individuals, those with higher CD4+ cell counts and lower WHO stage at ART initiation.ConclusionsOver time, enrollment in HIV care through outpatient PITC increased and patients enrolled into HIV care at earlier disease stages across all HIV testing points. However, median CD4+ cell count at ART initiation remained steady. Pre- and post-ART attrition (particularly in the first 6 months) have remained major challenges in ensuring prompt ART initiation and retention on ART.

Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis

“…Table 1 presents the main characteristics and outcomes of reviewed studies[7–10,23,28–30,39]. Studies were conducted from across Ethiopia and the majority of them were from the northern (4) and southern (3) part of the nation.…”

“…The studies were analytical in type including: three case control studies[7,9,23], five retrospective cohort studies[8,10,29,30,39] and one prospective cohort study[28]. The majority of the studies (n = 7)[8–10,28–30,39] assessed factors associated with LTFU and the remaining two studies[7,23] assessed defaulting. One study that assessed LTFU[28] also assessed ‘stopped treatment’.…”

“…A study from five East African countries revealed the existence of 14 different definitions of ART defaulting were in use[26]. Currently, the definition of LTFU in Ethiopia is also not uniform, and has included a patient discontinuing from ART for more than one[8], two[9], three[10,27–29] or twelve[30] months. Additional studies have considered a ‘defaulter’ when a patient discontinues from ART for more than two months [7,23].…”

Trends in clinical characteristics and outcomes of Pre-ART care at a large HIV clinic in Nairobi, Kenya: a retrospective cohort study

“…Upward trends in the proportion of enrolments from the VCT were also documented in a prospective cohort analysis of adult patients in Tanzania [19], and in a multi-country retrospective data review of older HIV positive adults [20]. A recent retrospective study in Ethiopia however, reported an increase in the proportion of adults enrolling into care through PITC services over time [21]. However, this analysis was done at a time when PITC services were being scaled up in the country which may have biased the findings.…”

“…Study limitations are inherent in the data source. We used routinely collected clinical data, which is more prone to errors, including missing information [21]. …”